DR Registration - Carey Baptist Association

Date

MM slash DD slash YYYY

Location

Please select class you are attending TODAY*

Please select classes you have attended PREVIOUSLY*

Gender

Male
Female

Name*

First Last

Spouse's Name

First Last

Street Address Address Line 2 City State ZIP Code

Social Security Number

Email*

Mobile Phone*

Daytime Phone

Evening Phone

Church Membership*

Association

Emergency Contact and Medical Information

Each volunteer is expected to have insurance in case of accident, injury, or illness. NO insurance coverage is provided volunteers by the Louisiana Baptist Convention or the team on which the individual is volunteering. Personal liability is the responsibility of the volunteer.

INSURANCE COMPANY:

Emergency Contact #1*

First Last

Contact #1 Phone

Emergency Contact #2

First Last

Contact #2 Phone

Southern Baptist Disaster Relief Release and Indemnity Agreement*

I do hereby represent and acknowledge I am entering a missionary venture with others; as a volunteer I am paying my own expenses, including insurance, for the purpose of helping in times of disaster for the glory of God and to demonstrate my faith in Christ; that the work may at times be hazardous and somewhat arduous and will be performed by concerned volunteers and qualified professionals trained in disaster relief work; that vehicles transporting these volunteers will be operated by licensed volunteers, who may or may not be professional drivers.

I recognize and acknowledge potential accidents at the disaster site, involving motor vehicles, in or about the living, sleeping and eating areas, or during activities of the disaster relief team; am fully aware of possible injuries to members of the disaster relief team, including myself.

Therefore, I desire to protect, release, acquit, indemnify and hold harmless from any and all claims, injuries, damages, losses, expenses or attorney fees incurred by me, my heirs, administrators, executors or assigns.

For and on behalf of myself, my heirs, administrators, executors, assigns and all other persons, firms, or corporations, I do hereby release and discharge from liability all other persons on the disaster relief team with me, those who notified, selected or assigned me to said team, the Louisiana Baptist Convention, state Disaster Relief director or department, Baptist Convention, their employees and representatives, successors or assigns, from any claims, demands, damages, actions, causes of actions which I, the undersigned, have or may hereafter, and on account of, or any way growing out of injuries or damages both to persons or property resulting or that may hereafter result from the voluntary venture.

This waiver, release and indemnity agreement is fully understood by me and I enter the same willingly for the purpose herein above stated.

Agree